Allegiance Benefit Plan Mgmt.
  • 07-Aug-2017 to 06-Oct-2017 (MST)
  • Missoula, MT, USA
  • Full Time

REPORTS TO: Network Services Manager LOCATION: Missoula FLSA STATUS: Non-Exempt


POSITION RESPONSIBILITIES: The Network Services Specialist is responsible for the accurate and timely repricing of claims according to PPO contract provisions, and all support functions necessary to secure correct discounts and provide requested information. The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.

ESSENTIAL JOB FUNCTIONS: Essential job functions include the following. Other functions may be assigned as business conditions change.

1.Interprets provider network contracts; directs claims to the proper PPO for out-of-house discounting or manuallyenters claim into online repricing system, and submits repriced claims to claims examiners for processing.
2.Reprices claims for all injectible drugs.
3.Responds to claims pricing and general PPO inquiries from plan participants, providers, networks, claimsexaminers, and customer service representatives.
4.Troubleshooting and resolution of system issues/errors resulting in out-of-house pricing denials.
5.Compiles and maintains claims, discounts, fees, refund requests, and savings data on each client group inspreadsheet format.
6.Word-processes letters explaining procedures and in response to questions regarding repricing.
7.Prints "personalized" PPO directories off the Internet for clients and plan participants as requested.
8.Updates provider addresses in the claims processing system.
9.Reviews PPO invoices; ensures credits are properly applied; approves for payment.
10.Coordinating the flow of documents and correspondence submitted by members or providers either to Allegiancethat need to be routed to a network for review, or vice versa, from the network to Allegiance.
11.Contributes to the daily workflow with regular and punctual attendance.

NON-ESSENTIAL JOB FUNCTIONS:
1.Provides assistance with pharmacy network set-up, programming and provider database maintenance.
2.Receives and distributes mail; collects claims, correspondence and invoices to the mailroom for scanning.
3.Performs related or other assigned duties as required or directed.

SUPERVISION EXERCISED:
None.

PHYSICAL WORKING CONDITIONS:
Physical requirements are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Sitting 80% Reaching Some Standing 10% Manual Dexterity High Walking 10% Telephone Yes Kneeling Some Computer Screen High (visual acuity corrected to 20/30) Bending Some Lifting up to 30 pounds

JOB SPECIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Minimum Education: High school graduation or GED required. College degree and/or training in medical terminology preferred.
Certification(s) Required: None.
Minimum Experience: Previous experience with computer software applications is required. Work experience with group health benefits or in the health insurance industry preferred.
Other Qualifications: Excellent oral and written communication skills required.
PC skills, including Windows, Excel, Access, Word, internet navigation, and emailapplications. Ability to learn all functions of the claims processing software as isnecessary for data entry, research and report generation. Must be able to adapt tosoftware changes as they occur.
Accurate data entry and typing skills.
Knowledge of medical terminology, basic health insurance concepts and repricingsystems.
Excellent listening skills.
Basic mathematical skills. Ability to calculate and obtain correct discounts fromproviders as stipulated by contract.
Ability to gain thorough knowledge of managed care systems, contracting, and healthcare economics.
High level of interpersonal skills to work effectively with others.
Ability to organize and recall large amounts of detailed information.
Ability to project a professional image and positive attitude in any work environment.
Ability to comply with privacy and confidentiality standards.
Ability to be flexible, work under pressure and meet deadlines.
Ability to analyze and solve problems with professionalism and patience, and toexercise good judgment when making decisions.
Ability to take initiative and work independently.
Ability to operate typical office equipment.
Working knowledge of general office procedures

Allegiance Benefit Plan Mgmt.
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